<div class="row">
    <div class="am-u-sm-12 am-u-md-12 am-u-lg-12">
        <div class="widget am-cf">
            <div class="widget-head am-cf">
                <div class="widget-title  am-cf">视力筛查</div>
            </div>
            <div class="widget-body  am-fr">
            	<form class="am-form tpl-form-line-form" data-am-validator action="{{urlfor "ScreeningController.Save"}}" id="doMySubmit">
                  <input type="hidden" name="Id" id="Id" value="{{.m.Id}}">
                    <div class="row am-cf">
                      <div class="am-form-group am-u-sm-12 am-u-md-6 am-u-lg-6">
                          <label class="am-u-sm-2 am-form-label">真实姓名：</label>
                          <div class="am-u-sm-10">
                               <div class="am-input-group am-input-group-sm tpl-form-border-form cl-p">
                                    <input name="Realname" type="text" id="Realname"  placeholder="长度不超过20" max="20" value="" required/>
                                    <span class="am-input-group-btn">
                                        <button class="am-btn am-btn-default am-btn-warning tpl-table-list-field" type="button" id="getOrderRow">顺序获取</button>
                                    </span>
                                </div>
                               
                           </div> 
                      </div>
    
    
                      <div class="am-form-group am-u-sm-12 am-u-md-6 am-u-lg-6">
                          <label class="am-u-sm-2 am-form-label">联系手机：</label>
                          <div class="am-u-sm-10">
                               <input type="text" class="am-form-field" id="Mobile" name="Mobile" value="" placeholder="输入手机号" required>
                         </div> 
                      </div>
             		</div>
                    <div class="row am-cf">
    
                      <div class="am-form-group  am-u-sm-12 am-u-md-6 am-u-lg-6">
                          <label class="am-u-sm-2 am-form-label">性别：</label>
                          <div class="am-u-sm-10">
                                  <label class="am-radio-inline">
                                    <input type="radio"  name="Sex" value="男" required> 男
                                  </label>
                                  <label class="am-radio-inline">
                                    <input type="radio" name="Sex" value="女"> 女
                                  </label>
                           </div> 
                      </div>
                 
                  
                      <div class="am-form-group am-u-sm-12 am-u-md-6 am-u-lg-6">
                          <label class="am-u-sm-2 am-form-label">年龄：</label>
                          <div class="am-u-sm-10">
                               <input name="Age" type="number" id="Age"  placeholder="必须是一个数字" value="" required/>
                           </div> 
                      </div>
                      </div>
                      <div class="row am-cf">
                      <div class="am-form-group am-u-sm-12 am-u-md-6 am-u-lg-6">
                          <label class="am-u-sm-2 am-form-label">生日：</label>
                          <div class="am-u-sm-10">
                               <input name="Birthday" type="text" id="Birthday"  placeholder="请选择出生年月" value="" data-am-datepicker readonly />
                           </div> 
                      </div>
                     
                      
                      <div class="am-form-group am-u-sm-12 am-u-md-6 am-u-lg-6">
                          <label class="am-u-sm-2 am-form-label">身份证号：</label>
                          <div class="am-u-sm-10">
                               <input name="Idcard" type="text" id="Idcard"  placeholder="请输入18位身份证号" value=""/>
                           </div> 
                      </div>
                  </div>
                  <div class="row am-cf">
                      <div class="am-form-group am-u-sm-12 am-u-md-6 am-u-lg-6">
                              <label class="am-u-sm-2 am-form-label">所在学校：</label>
                              <div class="am-u-sm-10">
                                   <input name="SchoolName" type="hidden" id="SchoolName" value=""/>
                                   <select data-am-selected="{searchBox: 1,maxHeight:'300px',btnWidth: '100%'}" placeholder="请选择所在学校" name="SchoolId" id="SchoolId" required>
                                        <option value=""></option>
                                        {{range $k, $v := .s}}
                                            <option value="{{$v.Id}}">{{$v.SchoolName}}</option>
                                        {{end}}
                                   </select>	
                               </div> 
                       </div>
                       <div class="am-form-group am-u-sm-12 am-u-md-6 am-u-lg-6">
                          <label class="am-u-sm-2 am-form-label">所在班级：</label>
                          <div class="am-u-sm-10">
                               <input name="Classes" type="text" id="Classes"  placeholder="请输入所在班级" value=""/>
                           </div> 
                      </div>
                      </div>
                      <div class="row am-cf">
                      <div class="am-form-group am-u-sm-12 am-u-md-6 am-u-lg-6">
                          <label class="am-u-sm-2 am-form-label">学生学号：</label>
                          <div class="am-u-sm-10">
                               <input name="SerialNumber" type="text" id="SerialNumber"  placeholder="请输入学号" value=""/>
                           </div> 
                      </div>
                      </div>
                      <div class="row am-cf">
                      <div class="am-form-group am-u-sm-12 am-u-md-6 am-u-lg-6">
                          <label class="am-u-sm-2 am-form-label">左眼视力：</label>
                          <div class="am-u-sm-10">
                               <input name="LeftEye" type="number" id="LeftEye"  placeholder="请输入左眼视力" value="" required/>
                           </div> 
                      </div>
                      <div class="am-form-group am-u-sm-12 am-u-md-6 am-u-lg-6">
                          <label class="am-u-sm-2 am-form-label">右眼视力：</label>
                          <div class="am-u-sm-10">
                               <input name="RightEye" type="number" id="RightEye"  placeholder="请输入右眼视力" value="" required/>
                           </div> 
                      </div>
                  </div>
  
                 <div class="am-form-group am-u-sm-12 am-u-md-12 am-u-lg-6">
                 	  <label class="am-u-sm-2 am-form-label"></label>
                      <div class="am-u-sm-10">
                        <button class="am-btn am-btn-secondary" type="submit">确认提交</button>
                        <button class="am-btn am-btn-default" type="reset">重置</button>
                      </div>
                  </div>
                 
                </form>
            </div>
        </div>
    </div>
</div>